Prior Authorization: The Pain Remains the Same



ORLANDO -- Technology solutions to some of the problems with prior authorization exist, but payers have to be willing to step up and implement them, several speakers said here.

"Everyone agrees we want to do these things, and then what do we actually do about it?" said Tyler Scheid, JD, senior policy analyst for administrative simplification issues at the American Medical Association (AMA) in Chicago. "When push comes to shove, we agree we're going to do something, but we come up short before we actually get to doing something. As we get a little more vocal and show the world what the problems really are, I think a little media pressure can potentially be an effective approach."

Prior authorization -- the requirement from insurers that providers get pre-approval before they order a particular test, drug, device, or procedure -- remains a big problem for clinicians and patients, Scheid said Wednesday at the Healthcare Information and Management Systems Society (HIMSS) annual meeting.

He cited data from the AMA's 2018 prior authorization survey, which found that 65% of 1,000 physicians surveyed said they had to wait at least 1 business day for a prior authorization (PA) decision, and 26% reported waiting for 3 business days.

In addition, 91% of physicians reported that PA led to delays in care, and 75% said it led, in at least some cases, to treatment abandonment. And despite previous efforts to address the problem, 88% of physicians reported that their PA burdens had actually increased over the last 5 years.

Reform Principles Released

One important landmark in these efforts to reduce PA's burden was the 2017 release of PA and utilization management reform principles, said Heather McComas, PharmD, AMA director of administrative simplification issues.

The idea behind the principles were agreed to by the AMA and 16 other organizations. The principles dealt with clinical validity, continuity of care, transparency and fairness, timely access and administrative efficiency, and alternatives and exemptions, McComas explained. "The point of the principles was to actually get people talking about this topic, and get peers and vendors talking about how we can improve this process."

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Heather McComas, PharmD, American Medical Association (Photo by Joyce Frieden)

Then in 2018, a consensus statement was released; this document was a collaboration between the AMA, the American Hospital Association, America's Health Insurance Plans, the Blue Cross and Blue Shield Association, the American Pharmacists Association, and the Medical Group Management Association. "This consensus statement [contained] a subset of principles talking about transparency, automation, and ensuring continuity of care," said McComas. "Both plans and providers agreed we should ensure reduction of PA."

This could include, for example, having insurers selectively apply PA criteria to doctors who have a pattern of ordering drugs differently from their peers, rather than making every doctor go through it. "We were also recommending that payers regularly look at their list of drugs that require PA and get things off the list that are almost always approved."

On the flip side, another idea is to give certain physicians whose ordering patterns are within general norms a "gold card" that would exempt them from having to go through PA, McComas said. While there is some concern that a doctor who is given a gold card could then go on an inappropriate ordering spree, "we realize there is a tracking component there to make sure [the doctor's] ordering remains consistent with evidence-based guidelines," she added.

One problem with a "gold card" is that it might be hard for providers to really know which services they are actually exempted from having to go through PA for, McComas said. "As they're ordering or prescribing something in the electronic health record (EHR), it needs to be clear to them that they're exempt from PA for that service for that payer. That information is somehow going to have to get flagged in the EHR, so some kind of tech solution is needed here."

Slow Growth for ePA

Electronic prior authorization (ePA), in which the process is automated more than it is today, is something the AMA supports, "but it is just one piece of the pie," said McComas. Another area of common interest is making PA requirements more transparent to physicians, so they know what approval criteria must be met.

Currently, PA is still largely manual and requires lots of faxing and phone calls, said McComas. "It's costly for everyone involved."

Although ePA has been around for several years, it's only recently that the Centers for Medicare & Medicaid Services has called on states to support it, said Scheid. At that level, several states -- Minnesota, Delaware, and Ohio -- now require payers to accept ePA requests for prescription drugs.

One survey found that 96% of payers are committed to an ePA solution and 79% of EHRs are committed to implementing ePA, Scheid said. "But overall adoption is sluggish ... One reason is a lack of physician awareness," as the AMA has found that only 51% of surveyed physicians were aware of ePA technology. And vendors say they haven't prioritized ePA because providers aren't demanding it, "so it's like a ... [29.29] circle that doesn't have a beginning."

"How do we overcome these challenges? Everything depends on creating physician awareness of ePA and its advantages," said Scheid. "Vendors also must assure that all information related to physicians at the point of care is accurate and up to date."

Keeping the Workflow Going

One effort to extend ePA to prescribing drugs is called the Real-Time Prescription Benefit (RTPB), which gives patient-specific drug benefit cost information within the e-prescribing workflow, he explained. However, "it's still a relatively new technology and adoption is still relatively low." Although some vendors and pharmacy benefit managers (PBMs) have introduced promising RTPB pilot programs, "one of the biggest issues is that none of them provide coverage for all payers."

To address some of these issues, the National Council for Prescription Drug Programs RTPB Task Group is developing an RTPB standard, which the AMA is hoping will be finalized by year's end, said Scheid. The standard would allow for two standard formats and would include an implementation guide for providers.

Another project in this area is the HL7 Da Vinci project, a private-sector initiative that is leveraging the HL7 version of Fast Healthcare Interoperability Resources (FHIR) to improve data sharing, Scheid said.

Source: https://www.medpagetoday.com/meetingcoverage/himss/78025

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